The South Asia Channel

The doctor isn't in

Over the last few weeks, Pakistani doctors have staged several strikes and taken to the streets to protest. The most recent strike ended on Monday morning after a 20-day work stoppage.

The chief demand of these physicians, most of them young and based at public facilities in Punjab Province, has been the establishment of a formal pay structure-one allowing for regular promotions to higher pay scales-already available to other public servants in Pakistan. "I have personally seen doctors who have served for more than 18 years and still remain in the same pay scale," one young doctor wrote several days ago.

The doctors' discontent, however, represents only one symptom of the disease afflicting Pakistan's troubled medical field.

Recall, for example, the much-publicized case of Imanae Malik. This three-year-old girl died at Doctors Hospital in Lahore in 2009 after an ER doctor (who her parents claim was half asleep) injected her with too much anesthesia-even though Malik had been admitted for a small burn on her hand (Malik's father now runs a website that catalogues dozens of other allegations of mistreatment at the same hospital). Or consider the seven newborns who burned to death last month in a fire caused by a short circuit in the nursery of another Lahore hospital. Grieving parents alleged that the hospital had no fire extinguishers, and witnesses reported that hospital staff ran away from the burning room instead of attempting to save the babies (hospital spokespeople later clarified that extinguishers were present, but staff didn't know how to use them).

Unfortunately, such medical malpractice and negligence are legion in Pakistan. One recent report tells of a surgeon who left a pair of scissors inside a man's stomach; of a doctor who removed a teenager's appendix when the actual diagnosis was colorectal cancer; and of physicians' constant failure to detect common jaundice in newborns, leading to many deaf and brain-damaged babies. Little wonder the striking doctors have not garnered overwhelming public support; some Pakistanis have denounced them as "heartless" and even as "miscreants"-an epithet the nation often invokes against terrorists.

Incompetence may be partially to blame, yet these problems are largely attributable to a severely overburdened and underresourced medical profession. In most rural areas, there are more than 1,200 patients for every doctor; another estimate finds that, nationwide, there are 18,000 people for every doctor. These are profound paucities for one of the world's sickest nations. No country has more polio cases, only Nigeria suffers more stillbirths, and only five nations have more tuberculosis patients. A third of Pakistan's population is undernourished, and nearly half of it lacks access to safe water. Meanwhile, according to an Al Jazeera study, up to 16 percent of Pakistanis suffer from mental illness-and the ratio of severely-ill patients to doctors is 2,000 to 1. Not surprisingly, doctors speak of having to work for 28 days per month and up to 30 hours in a row.

Unfortunately, government support is woefully insufficient. Only 0.2 percent of the 2012-13 federal budget is expected to be allocated to the health sector (this compares to 24 percent for the United States). In fiscal year 2010-11, a mere 0.27 percent of GDP went to health. A doctor fresh out of medical school working for a public sector facility receives about $250 per month, claim those who have gone on strike; by comparison, a court stenographer receives nearly $700 (last year Islamabad announced doctors' salaries would be increased to about $530 a month; it's unclear if this change has gone into effect).

With overworked, underpaid medical workers facing a constant stream of patients, the Hippocratic Oath is often turned on its head. According to doctors speaking anonymously, harried medical staff-in their haste to get to the next patient-become careless and leave surgical materials (from cotton to the aforementioned scissors) inside patients' bodies. And in their desperation to earn more income, physicians often tamper with pathology reports to justify surgery-which can generate lucrative fees-even if prescribing medication is the proper course.

Predictably, in light of this sad state of affairs, Pakistani doctors often voice a desire to leave the country. Many have already done so-and quite a few have come to the United States. According to a New York Times study, doctors account for the fourth most common profession of Pakistan-born U.S. workers. The Association of Physicians of Pakistani Descent of North America (APPNA)-which just held its annual convention at the cavernous Gaylord Convention Center near Washington, DC-is one of the larger Pakistani diaspora organizations in America.

Still, many choose to continue practicing in Pakistan, despite the problems-and the risks. I recently spoke with a young vascular surgeon based at one of the country's better public hospitals. His main concern is not a low salary or high caseload, but rather his own safety. He told me that frustrated people-denied care, or forced to endure long waiting periods-often roam around the hospital looking for doctors to beat up. The problem is so severe, he said, that he wears his telltale scrubs only when absolutely necessary.

Ultimately, Pakistan's medical crisis exemplifies the disparities between the nation's public and private sectors. The most overburdened and underpaid doctors-and those on the picket lines-work for public institutions. Private medical care is generally more expensive but of better quality and more sufficiently resourced than public care (the private Doctors Hospital, where Imanae Malik died, is one of the few exceptions).

A stark illustration of this public-private divide is ambulatory services. Several years ago, the Karachi mayor's office presented me with a glossy publication highlighting the city government's accomplishments. One photo depicted a fleet of new and sleek government-issued ambulances. Yet today, they likely no longer exist. According to media reports last month, Karachi's few public ambulances have been abandoned due to technical problems, "and are rusting away somewhere." A bevy of private ambulance operators have filled this vacuum. They include the Edhi Foundation, run by octogenarian philanthropist Abdul Sattar Edhi, which manages hundreds of ambulances. Across the nation, the supply and capacity of private ambulances far outstrip those of publicly provided ones. (Sindh's health minister has even suggested that public ambulances have been used for shopping excursions instead of emergency response.)

Pakistan's medical crisis is unlikely to be resolved unless the Pakistani government takes several unprecedented steps. One is to allocate more public funding to the health sector-an adjustment that may not please Pakistan's powerful military, which for years has enjoyed a disproportionate share of the national budget. Another is to actually implement (as opposed to merely formulate or approve) public policies that seek to improve the health of the Pakistani people.   

Unfortunately, Islamabad seems to be moving in a very different direction. Last year, the government passed the 18th constitutional amendment, which devolves many central government functions to the provinces. The responsibilities and resources of Pakistan's federal health ministry have been passed on to provincial governments-which lack the capacities to take on such a vastly expanded portfolio.

Additionally, Pakistan's private sector is playing an increasingly prominent role in medical care; it presently accounts for about 80 percent of outpatient health care visits. On one level, given the crisis in public care, this is a welcome development. Promising new initiatives abound, including one called Naya Jeevan. For a nominal monthly fee, this program offers low-income domestic household workers and uninsured factory laborers access to private health care services.

However, the growth of private medical care is of no use for the millions of poor and unemployed who can afford neither the high standard costs of private care nor the subsidized costs levied by the likes of Naya Jeevan. And expanded private health services offer little consolation to the overburdened public sector doctors who must minister to Pakistan's public care-dependent ill and impoverished.

The takeaway? As is often the case, the Pakistani masses-and those charged with helping them-are the biggest losers.

Michael Kugelman is the South Asia associate at the Woodrow Wilson International Center for Scholars in Washington, DC. He can be reached by email at michael.kugelman@wilsoncenter.org and on Twitter @michaelkugelman.

ASIF HASSAN/AFP/Getty Images

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